Provider Demographics
NPI:1518323799
Name:CARPENTER, KASSANDRA JEAN (AA)
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:JEAN
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:KASSANDRA
Other - Middle Name:
Other - Last Name:WIENHOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA
Mailing Address - Street 1:809 82ND PKWY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:809 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-692-1062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL49367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant